Clinical skills for the thorax, heart and greater vessels

Question 1

What are the 4 parts of the physical examination of the chest?

Answer 1

1- visual inspection
2-palpation
3-percussion
4-Auscultation

Question 2

What should you feel on the anterior surface of the thorax?

Answer 2

locate and palpate various bony landmarks and be able to count the ribs and intercostal spaces

Using the bony landmarks it is also possible to map the underlying heart and its pericardial reflections and the lung and its pleural reflections

Question 3

Where can palpatations of the apex of the heart be felt in males?

Answer 3

Fifth intercostal space just lateral to the mid clavicular line

Question 4

How do you palpate the beating of the heart in females?

Answer 4

Raise the breast and place hand beneath it

Question 5

What happens when you tap the chest with your fingers?

Answer 5

produces dull note over the heart-this gives you a rough estimate of the size of the heart

Question 6

What produces sounds from the heart and how can you hear them?

Answer 6

Use a stethoscope

Sounds are caused by the closure of the heart valves and the blood flow across them produce the heart sounds

Aortic and pulmonary valves are best heard in the second right and second left intercostal spaces respectively

Tricuspid valve- best heard over the left 5th intercostal space at the sternal border

Mitrial valve - best heard beat areaover the apex

Question 7

Where does the heart lie?

Answer 7

middle mediastinum just behind the sternum

About 2/3 of the heart lies to the left of the mid sternal line (MSL), whilst 1/3 of it lies to the right of the MSL.

Question 8

What does the heart sit in?

Answer 8

pericardial sac which is attached to the diaphragm. Therefore, the shape and position of the heart varies as it moves with the diaphragm during the respiratory cycle.

Question 9

What bony structures on the surface can tell us about deeper lying structures such as the outline of the heart and anterior chest wall?

Answer 9

ribs, sternum, clavicle, thoracic vertebrae, and scapulae

You should be able to count the ribs and intercostal spaces as well as identify important bony landmarks including; suprasternal (jugular) notch, sternal angle, xiphisternal joint, costal margins and midclavicular lines.

Question 10

What 4 points should you be able to mark to form the four borders of the heart?

Answer 10

1-3rd CC, 1cm from the sternal border(top right corner)

2-6th CC, 1cm from the sternal border(bottom right corner)

3-5th ICS to apex beat at the MC(midclavicular line) line(9cm) (bottom left corner)

4-2nd ICS/2nd CC, 2.5cm sternla border

Question 11

What is the apex beat?

Answer 11

Pulsation-either visible or palpable or both, caused by the APEX OF THE LEFT VENTRICLE OF THE HEART when it is forced against the anterior chest wall during contraction

By definition, the most lateral and inferior point at which the palpating fingers raise with each systole defines the position of the apex beat. (the apex beat may not be palpable in many patients)

Question 12

What is the anatomical apex of the heart?

Answer 12

The point where the neurovascular bundle enters the root apex.

Question 13

Describe the steps used to palpate the apex beat ?

Answer 13

1) Your colleague (or patient) should lie on a couch with head and back raised at 45 degrees.
2) You should approach and stand facing your colleague from their right side.
3) You should use your palm and 4 fingers of your right hand to palpate. You should align your fingers along the left 4th, 5th and 6th intercostal spaces.
4) You should start palpation from the left lateral chest wall (near the mid-axillary line), and move to the anterior chest wall (towards the mid-clavicular line).
5) If you find the apex beat difficult to palpate in your colleague, a brisk “jogging on the spot” by your colleague (for 1 minute) may increase the heart rate and strength of the heart beat that enables easier palpation.
6) In females, the examiner’s hand should be laid beneath the breast along its lower border (a mitral valvotomy scar could be missed if the apex beat is not visualised).

Question 14

where is the mid-axillary line?

Answer 14

side of the body form the middle of the armpit going down

Question 15

In children where is the apex beat found?

Answer 15

slightly higher on the 5th rib

Question 16

What does a shift in the apex beat laterally or inferially or both indicate?

Answer 16

ENLARGEMENTS(CARDIOMEGALY) of the heart

Occasionally can be due to chest wall deformity, mediastinal shift or underlying pleural and lung disease

Question 17

What is a ‘Heave’ beat?

Answer 17

An abnormal type of apex beat caused by HYPERTROPHY of the left ventricle

Sounds forceful and may extend outwards towards the axilla

Question 18

What is a ‘thrill’ beat?

Answer 18

A hyperkinetic and more sustained beat

characteristic of volume overload and may occur in heart failure and mitral and aortic regurgitation

Question 19

What is Dextrocardia?3)

Answer 19

when the apex beat is palpable on the left side of the sternum

Question 20

When may the apex beat not be palpable?

Answer 20

Patients with:

• thick chest wall
• emphysema
• pericardial effusion
• shock

Question 21

What does auscultate mean?

Answer 21

examine a patient by listening to sounds from the heart using a stethoscope

Question 22

At what sites and in what order do you auscultate the heart valves?

Answer 22

1) Mitral -left 5th intercostal space at the mid-clavicular line (= apex beat area).
2) Tricuspid -left 5th intercostal space near the sternum.
3) Pulmonary -left upper 2nd (or 3rd) intercostal space near the sternum.
4) Aortic- right upper 2nd intercostal space near the sternum.

Question 23

Where are the 4 valves of the heart located?

Answer 23

Embedded in the “fibrous skeleton” of the heart in the atrioventricular plane.

All valves are located behind the sternum on a line running from the medial end of the left 3rd costal cartilage (CC) to the medial end of the right 4th intercostal space (ICS).

Question 24

In what order are the valves arranged?

Answer 24

The order in which the valves are arranged is as follows:

• Pulmonary valve at the level of the 3rd costal cartilage.
• Aortic valve at the level of the 3rd intercostal space.
• Mitral valve at the level of the 4th costal cartilage.
• Tricuspid valve at the level of the 4th intercostal space.

Question 25

What are the 2 sounds produced by a normal heart?

Answer 25

“lub” or the 1st heart sound (S1) - due to closure of atrioventricular valves (low pitched)

“dub” or the 2nd heart sound (S2) due to closure of aortic and pulmonary valves (high pitched).

Question 26

Where do you apply the stethoscope to best hear the lub and dub sound?

Answer 26

anywhere on the ANTERIOR CHEST wall overt eh adjacent areas

Question 27

Why is the areas for best auscultation of the valves not always correlated with the anatomical location of the valves?

Answer 27

The sound produced by the valve is carried by the blood stream along the direction of flow via the valve

Therefore placing the stethoscope superficial to the blood filled space downstream of a given valve may allow the sound of that valve (including abnormal sounds) to be distinguished clearly from the sounds of other valves

Question 28

How do you palpate the pulse?

Answer 28

use INDEX and MIDDLE finger (ring finger optional)

don’t use thumb or pinky

Question 29

What characteristics can be evaluated by palpating various arterial pulses around the body?

Answer 29

Pulse rate – usually assessed by palpating right radial pulse and expressed in beats per minute.

Rhythm - usually assessed by palpating right radial pulse. The rhythm can be regular or irregular. Irregular rhythm is usually due to cardiac problems such as atrial fibrillation or ectopic beats.

Character and volume- usually assessed by palpating the right carotid artery pulse which is closest to the heart than the radial pulse.

Symmetry – of radial, brachial, femoral, popliteal, and pedal pulses can be assessed by comparing pulses on both sides.

Radio-femoral delays between major arteries might observed and are abnormal.

Question 30

What are the important arterial pulses in the upper limb?

Answer 30

Subclavian artery
Axillary artery
Radial pulse
Ulnari pulse
Brachial artery pulse

Question 31

What are the important arterial pulses in the Head and neck?

Answer 31

• Common carotid artery pulse(in between the naterior border of SCM muscle and thyroid cartilage)
• superficial temporal(in front of the tragus of the ear)

Question 32

Where is the internal jugular vein?

Answer 32

behind the carotid artery under the SCM

Question 33

What can the Internal Jugular vein be used for?

Answer 33

not palpable
Is accessible for cannulation in the region of the apex of the triangle formed by the clavicular and sternal heads of the SCM with the medial end of the clavicle

The vein is subcutaneous here

The right IJV is usually preferred because it is larger and straighter

Question 34

What is Venepuncture?

Answer 34

the puncture of a vein as part of a medical procedure, typically to withdraw a blood sample or for an intravenous injection.

Question 35

Where is the most common site for venepuncture?

Answer 35

CUBITAL FOSSA-veins are very prominent and accessible

Question 36

How can you demonstrate the superficial veins in the upper limb?

Answer 36

Apply pressure to the middle of the arm of your patient by encircling it with your hand

Whilst doing this ask patient to pump the hand by opening and closing their fist

This will cause venous congestion and distention of the veins

Question 37

In the cubital fossa region what veins are there?

Answer 37

median cubital vein which often connects the cephalic and basilic veins.

Question 38

Where do the basilic and cephalic veins originate from?

Answer 38

DORSAL VENOUS ARCH at the dorsum of the hand

Question 39

Describe the examination of arterial pulses?

Answer 39

1-palpate radial then ulnar artery(above the wrist)

2-ask them to bend there arm then relax it and feel arteries at eh elbow and then at the Brachial artery (middle of upper arm)

3-Ask them to tilt their head back and feel for the carotid artery

Question 40

When palpating the arterial pulses, at which landmarks are the arteries easily accessible in the Head and neck region?

Answer 40

Common carotid artery- Can be palpated in the neck, between the lateral side of thyroid cartilage and medial border of sternocleidomastoid muscle. This is the strongest pulse of all.

Superficial temporal artery- Can be palpated in front of the tragus of the ear. This vessel is a terminal branch of the external carotid artery.

Subclavian artery-Can be palpated in the supraclavicular fossa region, at the angle between clavicle and sternocleidomastoid muscle. At this site you can compress and occlude the artery completely.

Question 41

Why is assessment of the carotid pulse useful?

Answer 41

The carotid pulse is ideal for the assessment of the amplitude, shape and volume of the pulse that are important in the diagnosis of underlying heart disease.

Question 42

When palpating the arterial pulses, at which landmarks are the arteries easily accessible in the upper limb region?

Answer 42

Axillary artery- You can palpate the axillary artery pulse on the medial side of humerus (lateral wall of the axilla), posterior to the tendon of the short head of biceps.

Brachial artery (midarm)- You can palpate the brachial artery along middle third of the humerus, in the medial bicipital groove behind the medial border of biceps muscle.

Brachial artery pulse (in the cubital fossa)-More commonly done than midarm, the brachial is also palpable on the medial side of the tendon of biceps muscle and it is easier to palpate the pulse when the elbow is fully extended.

Radial artery (at the wrist)- Should palpated at the wrist over the distal end of radius lateral to the tendon of flexor carpi radialis muscle. The radial artery lies superficial and easily accessible.

Ulnar artery (at the wrist)-You can palpate the ulnar artery pulse at the wrist over the distal end of the forearm lateral to the tendon of flexor carpi ulnaris muscle.

Question 43

What is the most common artery used to measure a patients pulse rate and rhythm?

Answer 43

Radial artery